Zimbabwe is confronting the synergistic plagues of a generalized HIV epidemic and rapid economic decline. Both have contributed to the large number of orphans and vulnerable children (OVC) estimated at 1.5 million in 2007. Adolescent female OVC have limited access to educational and economic opportunities, are twice as likely to be HIV infected than their male counterparts, and are more likely than non-OVC to engage in high-risk sexual behavior. Among those that are HIV infected, economic vulnerability and the psychological consequences of being poor and HIV positive, increase the risk of secondary transmission and poor access to care. There is a clear need to address secondary prevention (of HIV transmission and of HIV- related psychological morbidity) in this vulnerable population; however, existing behavioral interventions are likely to have limited impact in that they do not address the fundamental economic factors conditioning behavior. It is critical that structural interventions that do address such factors be developed and evaluated. Through this continuation proposal, we propose to expand SHAZ! (Shaping the Health of Adolescents in Zimbabwe)-an HIV prevention intervention that empowers adolescent female OVC to avoid sexual risk behaviors by improving economic opportunities and linking them to life skills-based HIV education and clinical care-to HIV-positive participants. Building on pilot work among 20 HIV-positive participants integrated into the SHAZ! study, here we propose to conduct a full study of SHAZ! for Positives among 650 additional HIV-positive participants, all of whom will be linked to clinical care and then randomly assigned to the combined economic (vocational training, guidance counseling, and a micro-grant) and life skills intervention compared to the life skills intervention alone. Initiating this expansion while the main study is ongoing (targeted for completion in early 2009) will enable us to build on our existing infrastructure and, thus, effect substantial cost savings, as well as conceal the HIV status of study participants, facilitating our ethical mandate to ensure confidentiality. Through our proposed design-that brings together the Women's Global Health Imperative at RTI International, the University of Zimbabwe-UCSF Research Programme, the Pangaea Global AIDS Foundation and the HIV/AIDS clinic at the Chitungwiza Hosptial-we will evaluate the effect of SHAZ! for Positives on: (1) indicators of economic livelihoods and social resources; (2) adherence to care and treatment, and subsequent health outcomes; (3) psychosocial morbidity, disclosure, and coping skills; (4) behaviors associated with the secondary transmission of HIV, and (4.a) whether secondary transmission risk behavior is mediated by treatment outcomes or psychosocial factors. If this innovative SHAZ! for Positives model is proven effective, these findings will have far-reaching program and policy implications in the region and beyond. PUBLIC HEALTH RELEVANCE: This project (SHAZ!-Plus) aims to promote secondary prevention (of HIV transmission and of HIV-related psychological morbidity) among a highly vulnerable population: HIV-positive adolescent female orphans living in Zimbabwe. By addressing the underlying economic and social vulnerability of this population, SHAZ!-Plus has the potential to promote secondary prevention beyond the limited impact behavioral interventions are likely to have alone. If this innovative model is proven effective, these findings will have far-reaching implications for program planning and policy in the region and beyond.